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ZusammenfassungEpidemiologische Untersuchungen zeigen, dass etwa 2–3 % aller Österreicher*innen einen Diabetes mellitus mit Nierenbeteiligung aufweisen. Dies betrifft somit in Österreich etwa 250.000 Menschen. Das Risiko des Auftretens und Fortschreitens der diabetischen Nierenerkrankung kann durch Lebensstilinterventionen und Optimierung des arteriellen Blutdrucks, Blutzuckers und spezielle Medikamentenklassen vermindert werden. In diesem gemeinsamen Artikel der Österreichischen Gesellschaften für Nephrologie und Diabetologie werden die entsprechende Diagnostik und therapeutische Strategien bei diabetischer Nierenerkrankung vorgeschlagen.

Recent epidemiological investigations have shown that approximately 2-3% of all Austrians suffer from diabetes with renal involvement, i. e. 250,000 people in Austria are affected. The risk of occurrence and progression of this disease can be ameliorated by life style interventions as well as optimization of blood pressure, blood glucose levels and special drug classes. The present article represents the joint recommendations of the Austrian Diabetes Association and the Austrian Society for Nephrology for the diagnostics and treatment strategies of diabetic kidney disease.

Although nephrologists are responsible for the long-term care of dialysis patients, physicians from all disciplines will potentially be involved in the management of patients with kidney failure, including patients on peritoneal dialysis, the major home-based form of kidney-replacement therapy. This review aims to fill knowledge gaps of non-experts in peritoneal dialysis and to highlight key management aspects of in-hospital care of patients on peritoneal dialysis, with a focus on acute scenarios to facilitate prompt decision-making. The clinical pearls provided should enable non-nephrologists to avoid common pitfalls in the initial assessment of peritoneal dialysis-related complications and guide their decision regarding when to refer their patients to a specialist, resulting in improved multidisciplinary patient care.

Peritoneal transport characteristics and residual renal function require regular control and subsequent adjustment of the peritoneal dialysis (PD) prescription. Prescription models shall facilitate the prediction of the outcome of such adaptations for a given patient. In the present study, the prescription model implemented in the PatientOnLine software was validated in patients requiring a prescription change. This multicenter, international prospective cohort study with the aim to validate a PD prescription model included patients treated with continuous ambulatory peritoneal dialysis. Patients were examined with the peritoneal function test (PFT) to determine the outcome of their current prescription and the necessity for a prescription change. For these patients, a new prescription was modeled using the PatientOnLine software (Fresenius Medical Care, Bad Homburg, Germany). Two to four weeks after implementation of the new PD regimen, a second PFT was performed. The validation of the prescription model included 54 patients. Predicted and measured peritoneal Kt/V were 1.52 ± 0.31 and 1.66 ± 0.35, and total (peritoneal + renal) Kt/V values were 1.96 ± 0.48 and 2.06 ± 0.44, respectively. Predicted and measured peritoneal creatinine clearances were 42.9 ± 8.6 and 43.0 ± 8.8 L/1.73 m2/week and total creatinine clearances were 65.3 ± 26.0 and 63.3 ± 21.8 L/1.73 m2/week, respectively. The analysis revealed a Pearson's correlation coefficient for peritoneal Kt/V of 0.911 and Lin's concordance coefficient of 0.829. The value of both coefficients was 0.853 for peritoneal creatinine clearance. Predicted and measured daily net ultrafiltration was 0.77 ± 0.49 and 1.16 ± 0.63 L/24 h, respectively. Pearson's correlation and Lin's concordance coefficient were 0.518 and 0.402, respectively. Predicted and measured peritoneal glucose absorption was 125.8 ± 38.8 and 79.9 ± 30.7 g/24 h, respectively, and Pearson's correlation and Lin's concordance coefficient were 0.914 and 0.477, respectively. With good predictability of peritoneal Kt/V and creatinine clearance, the present model provides support for individual dialysis prescription in clinical practice. Peritoneal glucose absorption and ultrafiltration are less predictable and are likely to be influenced by additional clinical factors to be taken into consideration.

Diabetische Nephropathie ist die fuhrende Ursache der Nierenersatztherapie und die haufigste Nierenkrankheit geworden. Die Entwicklung und das Fortschreiten kann durch optimierte Therapie beeinflusst werden. Im vorliegenden Artikel werden die gemeinsamen Empfehlungen der Osterreichischen Diabetesgesellschaft und der Osterreichischen Gesellschaft fur Nephrologie dargestellt.

BackgroundCatheter-associated infections markedly contribute to treatment failure in peritoneal dialysis (PD) patients. There is much controversy surrounding prophylactic strategies to prevent these infections.MethodsIn this nationwide multicenter study we analyzed strategies to prevent catheter-associated infections as performed in Austrian PD centers in 2006. A questionnaire was sent to all 23 PD centers in Austria.ResultsTen different catheter models were used in the 332 patients being treated in the 23 Austrian PD centers. Systemic antibiotics prior to catheter placement were given by 17 of the 23 PD centers (glycopeptides, n = 7; cephalosporins, n = 10). Nasal swabs were taken preoperatively by 17 PD centers; nasal Staphylococcus aureus carriers were treated prophylactically with mupirocin cream in 15 of these centers. Dressing change was routinely performed in 318 of 332 chronic PD patients (nonocclusive film dressing, n = 58; gauze dressing, n = 260). Disinfectants for chronic exit-site care included povidone iodine ( n = 155), sodium hypochlorite ( n = 31), povidone iodine + sodium hypochlorite together ( n = 102), and octenidine dihydrochloride/phenoxyethanol ( n = 17). Water+non-disinfectant soap or 0.9% sodium chloride was administered as a cleansing agent to the exit site by 27 patients. Routine S. aureus screening (nasal and/or exit-site swabs) in chronic PD patients was performed in 12 PD centers; carriers were treated with mupirocin cream in 11 of these centers. Dialysis staff members were screened for S. aureus in 8 PD centers and spouses were screened for S. aureus in 5 PD centers. The overall exit-site infection rate was 1 episode/43.9 patient-months, tunnel infection rate was 1 episode/88.9 patient-months, and peritonitis rate was 1 episode/51.0 patient-months. Patients of centers that have installed a prophylaxis protocol for treating S. aureus carriers had lower mean infection rates compared with those not using such a protocol.ConclusionVarious individual prophylactic strategies are used to prevent catheter-associated infections in Austrian PD centers. Infection rates are within the range reported in the literature. There is still scope for improvement in some centers ( e.g., by establishing a prophylaxis protocol).

The objectives of this study were to evaluate whether adequate observation of abdominal pathologic features related to peritoneal dialysis (PD) was possible with magnetic resonance imaging (MRI) under routine conditions, i.e., against the background of the dialysate and without contrast medium. For 16 male and seven female patients (mean age, 51.8 +/- 15.0 yr; mean duration of PD, 324 +/- 542 d), 25 peritoneal MRI studies were performed with the intraperitoneal dialysate as usual. Indications were symptoms or combinations of symptoms, such as leakage or abdominal wall edema (n = 3), bloody dialysate (n = 4), suspected herniation (n = 1), suspected ultrafiltration failure (n = 2), and abdominal pain (n = 5), or routine assessment after initiation of PD (n = 12). The MRI protocol, which was performed with a 1.0-T scanner, consisted of breath-hold, coronal and transverse, T2-weighted, half-Fourier single-shot turbo spin-echo sequences, using a standard body-array coil. MRI studies were well tolerated and successfully completed for all except two patients. Results indicated a leak along the catheter (n = 1), a leak in an umbilical hernia (n = 1), suspected leakage (n = 1), hernias (n = 5, in three patients), intraperitoneal adhesions (n = 5, in four patients), a ruptured ovarian cyst (n = 1), and pleural effusions (n = 4). Pathologic findings unrelated to PD or located extra-abdominally were observed in 19 of the 25 studies. The catheter tip position was easily identified for all patients. In conclusion, this first report on peritoneal MRI using only dialysate as the "contrast medium" indicates that MRI permits detailed observation of all relevant, PD-related, abdominal pathologic features against the dialysate background, thus avoiding system contamination (and thus the risk of peritonitis).

Patienten mit Polyzystischer Nierendegeneration und terminaler Niereninsuffizienz werden in Osterreich zu 6 % und somit seltener der Peritonealdialyse (PD) als Nierenersatztherapie zugefuhrt als Patienten mit nicht-zystischen Nierenerkrankungen (ca. 8 %). In den USA praktizieren mehr als ein Funftel der Zystennieren-Patienten PD. Die Grunde fur diese Unterschiede sind unklar. Die bei dieser Erkrankung beschriebenen extrarenalen Manifestationen wie Divertikulose, erhohte Inzidenz der Hernienbildung oder Gefasaneurysmen konnten theoretisch mit erhohten Komplikationsraten an der PD verbunden sein. Entsprechende Untersuchungen weisen aber kein erhohtes Risiko fur Peritonitis durch Divertikulose und auch keine an der PD vermehrten Gefaskomplikationen nach. Hernien durften unabhangig von der Art der Nierenersatztherapie bei Polyzystischer Nierendegeneration gehauft auftreten und werden moglicherweise durch PD weiter gefordert. Die Dauer, wie lange PD durchgefuhrt werden kann, unterscheidet sich bei Zystennieren-Patienten nicht von der Therapiedauer bei Patienten mit nicht-zystischen Nierenerkrankungen. Zystennieren-Patienten mit abdominellen Beschwerden wie Meteorismus, Vollegefuhl oder Kreuzschmerzen verursacht durch die Organvergroserung sollte nicht unbedingt aktiv zur Peritonealdialyse geraten werden, da die Symptome durch die PD weiter verstarkt werden konnen. Gleiches gilt fur Patienten mit rezidivierenden Hernien. Allen anderen Zystennierenpatienten sollte aber sehr wohl die Methode zur Wahl vorgestellt werden, zumal Technikuberleben, Dialysequalitat oder methodenspezifische Komplikationsraten mit jenen bei Patienten mit nicht-zystischen Nierenerkrankungen vergleichbar sind. PD stellt auch fur Patienten mit Polyzystischer Nierendegeneration eine gleichwertige Behandlungsalternative zur Hamodialyse dar.

In einer multizentrischen „open label“ Studie mit IFN-α2b wurden 85 Patienten mit Haarzell-Leukamie behandelt und ausgewertet. Die Induktionsbehandlung bestand in 2 × 106 E IFN-α2b/m2, 3 × wochentlich, s.c. Die Ergebnisse zeigen die hohe Effektivitat der Substanz, wobei unter den verwendeten Dosierungen geringe, gut tolerierbare und passagere Nebenwirkungen im Sinne eines grippeahnlichen Syndroms auftraten. Die Prozentzahl der Remissionen (CR + PR + MR) nach sechsmonatiger Behandlungszeit lag bei 89%, der Anteil von CR betrug 4%, von PR 69%. An einer kleinen Gruppe (4 Patienten) wurde nach Erzielen einer CR oder PR der Effekt unterschiedlicher Formen der Erhaltungstherapie getestet. Die bisherigen, statistisch noch nicht auswertbaren Resultate sprechen dafur, das bei Auftreten eines Ruckfalles nach Aussetzen oder Verringerung der IFN-Dosis (3 × 106 I.E., s.c., 1 × wochentlich) durch Wiedereinsetzen oder Erhohung von IFN-α2 neuerlich Remissionen erzielt werden konnen. Zur Erhaltung der Remissionen durfte eine IFN-Dauertherapie notwendig sein. Mittels eines Kurzzeit in vitro Tests werde der Effekt von Interferon α2 auf die Inkorporation von H3-Thymidin und H3-Uridin in Haarzellen bestimmt. Fur beide Prakursoren ergab sich keine Hemmung des Einbaues. Allerdings zeigte eine Langzeitinkubation (48 h) einen signifikant vermehrten H3-Uridin Einbau, wahrend der H3-Thymidin Einbau unbeeinflust blieb. Diese Resultate sprechen gegen einen unmittelbaren antiproliferativen Effekt von IFN-α2 auf Haarzellen, sie weisen aber auf eine Induktion der RNS-Synthese hin. Eine Zellmarker-Analyse der Haarzellen mit monoklonalen Antikorpern vor und wahrend einer 7tagigen in vitro Behandlung mit IFN-α2 ergab keine Anderung des Phanotyps, so das eine differenzierende Wirkung des IFN auf Haarzellen nicht beobachtet werden konnte.

The efficacy of the benzodiazepine-antagonist flumazenil (Ro 15-1788) was evaluated in 26 patients with coma due to benzodiazepine self poisoning, alone or in combination with alcohol or other psychoactive drugs. 77% of the patients responded to the administration of a mean dose of 1.73 mg (range 0.2 to 8 mg) with immediate awakening or an improvement of at least 2 coma grades. In the patients without response (n = 3) or with minor improvement (n = 3) other psychoactive drugs turned out to be predominantly responsible for their comatose state. Adverse effects of flumazenil treatment such as altered blood pressure or increased heart rate were observed, but were generally mild. An acute benzodiazepine withdrawal syndrome was seen in 2 cases. In conclusion, flumazenil proved to be effective in the treatment of severe benzodiazepine intoxication. Beyond that, in cases of mixed overdosage or initially unknown diagnosis the antidote assisted in the clarification of the clinical condition.

We present a female patient with a B-immunoblastic lymphoma of the IgM-lambda type arising in angioimmunoblastic lymphadenopathy. An increased ratio of helper/inducer to suppressor/cytotoxic lymphocytes in the lymph node could have triggered the proliferation of B cells. Evolution of IgM cryoglobulinemia was paralleled by malignant transformation in the lymph node. A short-term in vitro chemosensitivity test could predict response to COP combination chemotherapy suggesting that in vitro chemosensitivity testing can be useful for the therapeutic management of angioimmunoblastic lymphadenopathy.

The objectives of this study were to evaluate whether age, sex, underlying renal disease, or the performing surgeon is of prognostic relevance to the patency of the vascular access. In a routine clinical setting, 139 first and 144 further fistula operations were done in 139 patients during 5 yr and were analyzed in retrospect. Within a group of 108 patients with first Cimino-Brescia fistulae, Cox multivariate regression analysis revealed the surgeon to be the only determinant with a continuous, significant effect on fistula patency throughout the observation period (P(out) < 0.1). The patency rates of the seven surgeons at 1, 2, and 3 yr differed from 34 to 69, 13 to 62, and 13 to 62%, respectively. Hazard ratios among the surgeons varied from 0.65 to 2.21. Additionally, age (P < 0.004) and diabetes mellitus (P < 0.02) were disclosed to be significant risk factors for impaired patency, but later in the course of disease (time dependent). Sex had no influence. After the failure of the first fistula, revisions of or new Cimino-Brescia fistulae (N = 56) were superior to polytetrafluoroethylene grafts (N = 61). The mean patency of the former amounted to 320 +/- 377 versus 156 +/- 281 days in polytetrafluoroethylene grafts (P < 0.05). It was concluded that increasing age and diabetes mellitus are time-dependent risk factors for the shortened patency of arteriovenous fistulae. The operating surgeon, however, seems to be the major determinant for the continuous patency of Cimino-Brescia fistulae.

The effect of human recombinant interferon alpha 2 (IFN alpha 2) on hairy cells obtained from 16 patients was evaluated. All patients promptly responded to induction of remission with 2 X 10(6) U/m2 interferon alpha 2 b, three times a week, sc. In order to achieve a more detailed insight into the mode of action of interferon in this disease, we determined the influence of IFN alpha 2 on the incorporation of radiolabeled thymidine and uridine into hairy cells. While both 3H-thymidine and 3H-uridine incorporation were unaffected by IFN alpha 2 in a 3-hour incubation period, a significant increase in uridine incorporation into hairy cells, but not CLL cells, was observed after 24 h. Cell surface marker analysis performed with monoclonal antibodies did not reveal a quantitative alteration of the immunophenotype of hairy cells in vitro. In addition, natural killer cells, assessed by monoclonal antibodies and a cytotoxicity assay against K 562 cells, were found to be decreased in 9 out of 10 patients prior to therapy. Although IFN alpha 2 could stimulate natural killer cells in vivo, we did not find a consistent correlation between the activation of these cells and the response to therapy. We conclude, therefore, that NK cells play no major role in the regression of hairy cells. Furthermore, IFN alpha 2 does not alter antigenic determinants in vitro, but leads to an enhanced incorporation of 3H-uridine into hairy cells in vitro, thus indicating a possible role for the induction of RNA synthesis in vivo.